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Grasso D, Galderisi S, Santucci A, Bernini A. Pharmacological Chaperones and Protein Conformational Diseases: Approaches of Computational Structural Biology. Int J Mol Sci 2023; 24:ijms24065819. [PMID: 36982893 PMCID: PMC10054308 DOI: 10.3390/ijms24065819] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Whenever a protein fails to fold into its native structure, a profound detrimental effect is likely to occur, and a disease is often developed. Protein conformational disorders arise when proteins adopt abnormal conformations due to a pathological gene variant that turns into gain/loss of function or improper localization/degradation. Pharmacological chaperones are small molecules restoring the correct folding of a protein suitable for treating conformational diseases. Small molecules like these bind poorly folded proteins similarly to physiological chaperones, bridging non-covalent interactions (hydrogen bonds, electrostatic interactions, and van der Waals contacts) loosened or lost due to mutations. Pharmacological chaperone development involves, among other things, structural biology investigation of the target protein and its misfolding and refolding. Such research can take advantage of computational methods at many stages. Here, we present an up-to-date review of the computational structural biology tools and approaches regarding protein stability evaluation, binding pocket discovery and druggability, drug repurposing, and virtual ligand screening. The tools are presented as organized in an ideal workflow oriented at pharmacological chaperones' rational design, also with the treatment of rare diseases in mind.
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Affiliation(s)
- Daniela Grasso
- Department of Biotechnology, Chemistry, and Pharmacy, University of Siena, 53100 Siena, Italy
| | - Silvia Galderisi
- Department of Biotechnology, Chemistry, and Pharmacy, University of Siena, 53100 Siena, Italy
| | - Annalisa Santucci
- Department of Biotechnology, Chemistry, and Pharmacy, University of Siena, 53100 Siena, Italy
| | - Andrea Bernini
- Department of Biotechnology, Chemistry, and Pharmacy, University of Siena, 53100 Siena, Italy
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Falcão de Campos C, Conceição I. Updated Evaluation of the Safety, Efficacy and Tolerability of Tafamidis in the Treatment of Hereditary Transthyretin Amyloid Polyneuropathy. Drug Healthc Patient Saf 2023; 15:51-62. [PMID: 36824481 PMCID: PMC9942506 DOI: 10.2147/dhps.s338577] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/26/2023] [Indexed: 02/19/2023] Open
Abstract
Hereditary amyloid transthyretin (ATTRv) amyloidosis is a devastating hereditary multisystemic disease affecting predominantly the peripheral and autonomic nervous systems and the heart. ATTRv is caused by mutations in the transthyretin (TTR) gene, leading to extracellular deposition of amyloid fibrils in multiple organs including the peripheral nervous system. If untreated, it is associated with a fatal outcome 10-12 years after disease onset. Different treatments are available for patients with ATTRv polyneuropathy. Tafamidis 20 mg is approved in Europe since 2011 for early stages of ATTRv polyneuropathy (stage I - able to walk without support) and it is recommended as first-line therapy in these patients. Tafamidis is a TTR stabilizer that selectively binds to TTR and kinetically stabilizes both wild-type native TTR and mutant TTR. Consequently, it has the potential to prevent the amyloidogenic cascade initiated by TTR tetramer dissociation into its monomers and subsequent misfolding and aggregation. Tafamidis is an oral drug, taken once per day, with proved efficacy, safety and tolerability in ATTRv-PN patients as demonstrated in different clinical trials and open-label extension studies as well in clinical practice setting with around 10 years of experience. Tafamidis treatment started in the earliest stages of the disease is associated with better neurological outcomes. A multidisciplinary approach in referral centres is also fundamental for monitoring patients to assess individual response to treatment.
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Affiliation(s)
- Catarina Falcão de Campos
- Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa-Norte, Lisbon, Portugal,Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal,Correspondence: Catarina Falcão de Campos, Department of Neurosciences, Hospital de Santa Maria, Av. Professor Egas Moniz, Lisbon, 1648-028, Portugal, Tel/Fax + 351 21 780521, Email
| | - Isabel Conceição
- Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa-Norte, Lisbon, Portugal,Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Dasgupta NR. Care of Patients With Transthyretin Amyloidosis: the Roles of Nutrition, Supplements, Exercise, and Mental Health. Am J Cardiol 2022; 185 Suppl 1:S35-S42. [PMID: 36549789 DOI: 10.1016/j.amjcard.2022.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022]
Abstract
Transthyretin (ATTR) amyloidosis is a debilitating disease that results in organ failure and eventual death. As the disease progresses, patients experience neurologic, gastrointestinal, and cardiovascular symptoms that increasingly compromise their nutritional status and exercise capacity. These symptoms cause considerable emotional stress and mental health challenges for patients and caregivers. This review summarizes common symptoms and mechanisms associated with malnutrition and exercise intolerance, and sources of emotional stress, and offers therapeutic strategies to address these issues. Although earlier diagnosis and disease-specific treatment are central to caring for patients with ATTR amyloidosis, additional attention to symptom-focused treatments to improve nutritional status, maintain exercise tolerance and capacity, and improve and maintain mental health are also important. In conclusion, a team-based approach involving multiple clinicians and providers can offer more comprehensive and coordinated care, support, and education for patients and caregivers.
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Affiliation(s)
- Noel R Dasgupta
- Department of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana.
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Ingenbleek Y. Plasma transthyretin is a nutritional biomarker in human morbidities. Front Med 2022; 16:540-550. [PMID: 35943703 PMCID: PMC9361973 DOI: 10.1007/s11684-022-0940-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/10/2022] [Indexed: 01/19/2023]
Abstract
Transthyretin (TTR) is a small liver-secreted plasma protein that shows close correlations with changes in lean body mass (LBM) during the entire human lifespan and agglomerates the bulk of nitrogen (N)-containing substrates, hence constituting the cornerstone of body building. Amino acids (AAs) dietary restriction causes inhibition of TTR production and impairs the accretion of LBM reserves. Inflammatory disorders result in cytokine-induced abrogation of TTR synthesis and urinary leakage of nitrogenous catabolites. Taken together, the data indicate that malnutrition and inflammation may similarly suppress the production of TTR through distinct and unrelated pathophysiological mechanisms while operating in concert to downsize LBM stores. The hepatic synthesis of TTR integrates both machineries, acting as a marker of reduced LBM resources still available for defense and repair processes. TTR operates as a universal surrogate analyte that allows for the grading of residual LBM capacity to reflect disease burden. Measurement of TTR is a simple, rapid, and inexpensive micro-method that may be reproduced on a daily basis, hence ideally suited for the follow-up of the most intricated clinical situations and as a reliable predictor of any morbidity outcome.
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Affiliation(s)
- Yves Ingenbleek
- Faculty of Pharmacy, Laboratory of Nutrition, University of Strasbourg, Route du Rhin, Illkirch-Graffenstaden, F-67401, Strasbourg, France.
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Karam C, Brown D, Yang M, Done N, Dieye I, Bozas A, Vera Llonch M, Signorovitch J. Factors Associated with Increased Health-Related Quality of Life Benefits in Patients with Hereditary Transthyretin Amyloidosis with Polyneuropathy (ATTRv-PN) Treated with Inotersen. Muscle Nerve 2022; 66:319-328. [PMID: 35766224 DOI: 10.1002/mus.27668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION/AIMS Hereditary transthyretin amyloidosis with polyneuropathy (ATTRv-PN) is a genetic condition associated with significant morbidity and mortality. We aimed to identify patient subgroups exhibiting the greatest health-related quality of life [HRQL] benefit from inotersen treatment. METHODS We examined data from the inotersen phase 2/3 randomized controlled trial for ATTRv-PN, NEURO-TTR (NCT01737398, 66 weeks). LASSO regression models predicted changes in Norfolk QoL-DN total score (TQoL, range -4 to 136; higher scores indicate poorer HRQL) from baseline in the inotersen and placebo arm, respectively. Individualized efficacy scores (ES) were calculated as differences between predicted change-scores had patients received inotersen vs. placebo. Patients were ranked by ES to define the greatest-benefit subpopulation (top 50%). Characteristics of the top 50% and bottom 50% of patients were compared. RESULTS The overall mean ± standard deviation TQoL change was -0.20±19.13 for inotersen (indicating no change) and 10.77±21.13 for placebo (indicating deterioration). Within the highest-benefit patients, mean TQoL change was -11.03±17.06 (improvement) for inotersen and 11.24±22.97 (deterioration) for placebo (P<0.001). Compared with the overall population, patients in the greatest-benefit subpopulation were younger, more likely to have polyneuropathy disability (PND) scores 1 or 2, less likely to have received prior tafamidis or diflunisal treatment, and more likely to have Val30Met mutations and higher (worse) baseline TQoL. CONCLUSION Patients who were younger and/or at earlier polyneuropathy stages experienced greater HRQL benefits from inotersen over 66 weeks. These findings underscore the need for early diagnosis and treatment initiation, especially among more severely affected patients in early stages of ATTRv-PN. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Chafic Karam
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Duncan Brown
- Ionis Pharmaceuticals/Akcea Therapeutics, Inc., Boston, Massachusetts, USA
| | - Min Yang
- Analysis Group, Inc., Boston, Massachusetts, USA
| | - Nicolae Done
- Analysis Group, Inc., Boston, Massachusetts, USA
| | - Ibou Dieye
- Analysis Group, Inc., Boston, Massachusetts, USA
| | - Ana Bozas
- Ionis Pharmaceuticals/Akcea Therapeutics, Inc., Boston, Massachusetts, USA
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Ishii T, Hirano Y, Matsumoto N, Takata A, Sekijima Y, Ueda M, Ando Y. Characteristics of Patients with Hereditary Transthyretin Amyloidosis and an Evaluation of the Safety of Tafamidis Meglumine in Japan: An Interim Analysis of an All-case Postmarketing Surveillance. Clin Ther 2020; 42:1728-1737.e6. [PMID: 32800381 DOI: 10.1016/j.clinthera.2020.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/22/2020] [Accepted: 07/02/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE An all-case, single-arm, observational, postmarketing surveillance is underway to assess the safety of tafamidis in patients with hereditary transthyretin (ATTRv) amyloidosis with peripheral polyneuropathy, also called transthyretin-type familial amyloid polyneuropathy, in Japan. Results from an interim analysis (data cutoff date, May 15, 2018) are presented in this preliminary report. METHODS Patients were registered and treated with tafamidis meglumine 20 mg/d in routine clinical practice (observation period, 156 weeks). Data on patient demographic and clinical characteristics and adverse drug reactions (ADRs) were captured using case-report forms. FINDINGS Of 219 patients included (mean age, 59.7 years; patients with age at disease onset ≥50 years, 61.2%; mean treatment duration, 95.5 weeks), 143 (65.3%) were male, 126 (57.5%) had a family history of ATTRv amyloidosis, and 149 (68.0%) originated from nonendemic areas. The most common ADRs were diarrhea (1.4%) and hematuria (0.9%). Six serious ADRs (pneumonia, bacteremia, malignant melanoma, pancreatic carcinoma, hematuria, and hereditary neuropathic amyloidosis [primary disease exacerbation]) were reported; no ADRs leading to death were recorded. IMPLICATIONS This interim analysis successfully provided comprehensive, nationwide epidemiologic data from 219 Japanese patients with ATTRv amyloidosis. The safety profile of tafamidis was largely consistent with that obtained from previous research. No new safety concerns were identified to date. Data presented in this interim analysis are subject to change following completion of the study, and we will continue to assess the safety and effectiveness of tafamidis throughout the study. ClinicalTrials.gov identifier: NCT02146378.
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Affiliation(s)
| | | | | | | | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Nagano, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Pharmacy, Nagasaki International University, Nagasaki, Japan
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Driggin E, Helmke S, De Los Santos J, Teruya S, Guadalupe S, Goldsmith J, Maurer MS. Markers of nutritional status and inflammation in transthyretin cardiac amyloidosis: association with outcomes and the clinical phenotype. Amyloid 2020; 27:73-80. [PMID: 31825676 DOI: 10.1080/13506129.2019.1698417] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Patients with transthyretin (TTR) cardiac amyloidosis demonstrate cardiac cachexia with progression of their cardiomyopathy, which is characterised by malnutrition and a heightened inflammatory state. How best to measure this condition is less well characterised. We investigated differences in survival among patients with ATTR cardiac amyloidosis by nutritional status as defined by modified BMI (mBMI) and by inflammatory state as defined by serum uric acid.Methods and results: This study was a retrospective analysis of patients diagnosed with ATTR cardiac amyloidosis at a single tertiary medical centre. Baseline characteristics were compared by nutritional status as measured by mBMI and by inflammatory state as measured by serum uric acid. Kaplan-Meier survival analyses were used to compare nutritional status and inflammatory status for the composite outcome of death. Cox proportional hazards modelling was used to assess predictors of death in this cohort. Three hundred patients (mean age 75 ± 11) years, 84.3% male) were included. Those with low mBMI (<1185 kg/m2 g/L) had shorter time to death (5.4 vs. 6.8 years, log rank p = .045) and those with elevated serum uric acid (>8.8 mg/dL) had shorter time to death (4.9 vs. 7.7 years, log rank p < .0001). Those with both low mBMI and elevated serum uric acid had the shortest time to death (4.3 years, log rank p = .005). In this cohort, mBMI was not a univariate predictor of death though there was a trend towards significance (HR 0.92, per 100 kg/m2 g/L, 95% CI 0.828-1.016, p = .099). Serum uric acid was a univariate predictor of death (HR 1.27 per 1 mg/dL, 95% CI 1.114-1.455, p < .001). In multivariate Cox analysis, this association remained significant (HR 1.31 per 1 mg/dL increase, 95% CI 1.096-1.560, p = .003) as well as in a separate stepwise model controlling for potential confounders including daily diuretic use, uric acid lowering therapy, and renal dysfunction.Conclusions: Both nutritional status as measured by mBMI and inflammation as measured by serum uric acid are associated with survival in patients with TTR cardiac amyloidosis however only serum uric acid is an independent predictor of death.
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Affiliation(s)
- Elissa Driggin
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Stephen Helmke
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | | | - Sergio Teruya
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Samantha Guadalupe
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Jeff Goldsmith
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Mathew S Maurer
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
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Magrinelli F, Fabrizi GM, Santoro L, Manganelli F, Zanette G, Cavallaro T, Tamburin S, Cochrane Neuromuscular Group. Pharmacological treatment for familial amyloid polyneuropathy. Cochrane Database Syst Rev 2020; 4:CD012395. [PMID: 32311072 PMCID: PMC7170468 DOI: 10.1002/14651858.cd012395.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Disease-modifying pharmacological agents for transthyretin (TTR)-related familial amyloid polyneuropathy (FAP) have become available in the last decade, but evidence on their efficacy and safety is limited. This review focuses on disease-modifying pharmacological treatment for TTR-related and other FAPs, encompassing amyloid kinetic stabilisers, amyloid matrix solvents, and amyloid precursor inhibitors. OBJECTIVES To assess and compare the efficacy, acceptability, and tolerability of disease-modifying pharmacological agents for familial amyloid polyneuropathies (FAPs). SEARCH METHODS On 18 November 2019, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase. We reviewed reference lists of articles and textbooks on peripheral neuropathies. We also contacted experts in the field. We searched clinical trials registries and manufacturers' websites. SELECTION CRITERIA We included randomised clinical trials (RCTs) or quasi-RCTs investigating any disease-modifying pharmacological agent in adults with FAPs. Disability due to FAP progression was the primary outcome. Secondary outcomes were severity of peripheral neuropathy, change in modified body mass index (mBMI), quality of life, severity of depression, mortality, and adverse events during the trial. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. MAIN RESULTS The review included four RCTs involving 655 people with TTR-FAP. The manufacturers of the drugs under investigation funded three of the studies. The trials investigated different drugs versus placebo and we did not conduct a meta-analysis. One RCT compared tafamidis with placebo in early-stage TTR-FAP (128 randomised participants). The trial did not explore our predetermined disability outcome measures. After 18 months, tafamidis might reduce progression of peripheral neuropathy slightly more than placebo (Neuropathy Impairment Score (NIS) in the lower limbs; mean difference (MD) -3.21 points, 95% confidential interval (CI) -5.63 to -0.79; P = 0.009; low-certainty evidence). However, tafamidis might lead to little or no difference in the change of quality of life between groups (Norfolk Quality of Life-Diabetic Neuropathy (Norfolk QOL-DN) total score; MD -4.50 points, 95% CI -11.27 to 2.27; P = 0.19; very low-certainty evidence). No clear between-group difference was found in the numbers of participants who died (risk ratio (RR) 0.65, 95% CI 0.11 to 3.74; P = 0.63; very low-certainty evidence), who dropped out due to adverse events (RR 1.29, 95% CI 0.30 to 5.54; P = 0.73; very low-certainty evidence), or who experienced at least one severe adverse event during the trial (RR 1.16, 95% CI 0.37 to 3.62; P = 0.79; very low-certainty evidence). One RCT compared diflunisal with placebo (130 randomised participants). At month 24, diflunisal might reduce progression of disability (Kumamoto Score; MD -4.90 points, 95% CI -7.89 to -1.91; P = 0.002; low-certainty evidence) and peripheral neuropathy (NIS plus 7 nerve tests; MD -18.10 points, 95% CI -26.03 to -10.17; P < 0.001; low-certainty evidence) more than placebo. After 24 months, changes from baseline in the quality of life measured by the 36-Item Short-Form Health Survey score showed no clear difference between groups for the physical component (MD 6.10 points, 95% CI 2.56 to 9.64; P = 0.001; very low-certainty evidence) and the mental component (MD 4.40 points, 95% CI -0.19 to 8.99; P = 0.063; very low-certainty evidence). There was no clear between-group difference in the number of people who died (RR 0.46, 95% CI 0.15 to 1.41; P = 0.17; very low-certainty evidence), in the number of dropouts due to adverse events (RR 2.06, 95% CI 0.39 to 10.87; P = 0.39; very low-certainty evidence), and in the number of people who experienced at least one severe adverse event (RR 0.77, 95% CI 0.18 to 3.32; P = 0.73; very low-certainty evidence) during the trial. One RCT compared patisiran with placebo (225 randomised participants). After 18 months, patisiran reduced both progression of disability (Rasch-built Overall Disability Scale; least-squares MD 8.90 points, 95% CI 7.00 to 10.80; P < 0.001; moderate-certainty evidence) and peripheral neuropathy (modified NIS plus 7 nerve tests - Alnylam version; least-squares MD -33.99 points, 95% CI -39.86 to -28.13; P < 0.001; moderate-certainty evidence) more than placebo. At month 18, the change in quality of life between groups favoured patisiran (Norfolk QOL-DN total score; least-squares MD -21.10 points, 95% CI -27.20 to -15.00; P < 0.001; low-certainty evidence). There was little or no between-group difference in the number of participants who died (RR 0.61, 95% CI 0.21 to 1.74; P = 0.35; low-certainty evidence), dropped out due to adverse events (RR 0.33, 95% CI 0.13 to 0.82; P = 0.017; low-certainty evidence), or experienced at least one severe adverse event (RR 0.91, 95% CI 0.64 to 1.28; P = 0.58; low-certainty evidence) during the trial. One RCT compared inotersen with placebo (172 randomised participants). The trial did not explore our predetermined disability outcome measures. From baseline to week 66, inotersen reduced progression of peripheral neuropathy more than placebo (modified NIS plus 7 nerve tests - Ionis version; MD -19.73 points, 95% CI -26.50 to -12.96; P < 0.001; moderate-certainty evidence). At week 65, the change in quality of life between groups favoured inotersen (Norfolk QOL-DN total score; MD -10.85 points, 95% CI -17.25 to -4.45; P < 0.001; low-certainty evidence). Inotersen may slightly increase mortality (RR 5.94, 95% CI 0.33 to 105.60; P = 0.22; low-certainty evidence) and occurrence of severe adverse events (RR 1.48, 95% CI 0.85 to 2.57; P = 0.16; low-certainty evidence) compared to placebo. More dropouts due to adverse events were observed in the inotersen than in the placebo group (RR 8.57, 95% CI 1.16 to 63.07; P = 0.035; low-certainty evidence). There were no studies addressing apolipoprotein AI-FAP, gelsolin-FAP, and beta-2-microglobulin-FAP. AUTHORS' CONCLUSIONS Evidence on the pharmacological treatment of FAPs from RCTs is limited to TTR-FAP. No studies directly compare disease-modifying pharmacological treatments for TTR-FAP. Results from placebo-controlled trials indicate that tafamidis, diflunisal, patisiran, and inotersen may be beneficial in TTR-FAP, but further investigations are needed. Since direct comparative studies for TTR-FAP will be hampered by sample size and costs required to demonstrate superiority of one drug over another, long-term non-randomised open-label studies monitoring their efficacy and safety are needed.
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Affiliation(s)
- Francesca Magrinelli
- University of VeronaDepartment of Neurosciences, Biomedicine and Movement SciencesPiazzale L.A. Scuro n. 10VeronaVRItaly37134
| | - Gian Maria Fabrizi
- University of VeronaDepartment of Neurosciences, Biomedicine and Movement SciencesPiazzale L.A. Scuro n. 10VeronaVRItaly37134
| | - Lucio Santoro
- University Federico II of NaplesDepartment of Neurosciences, Reproductive Sciences and OdontostomatologyVia Sergio Pansini n. 5NaplesItaly80131
| | - Fiore Manganelli
- University Federico II of NaplesDepartment of Neurosciences, Reproductive Sciences and OdontostomatologyVia Sergio Pansini n. 5NaplesItaly80131
| | - Giampietro Zanette
- Pederzoli HospitalNeurology SectionVia Monte Baldo n° 24Peschiera del GardaVRItaly37019
| | - Tiziana Cavallaro
- University of VeronaDepartment of Neurosciences, Biomedicine and Movement SciencesPiazzale L.A. Scuro n. 10VeronaVRItaly37134
| | - Stefano Tamburin
- University of VeronaDepartment of Neurosciences, Biomedicine and Movement SciencesPiazzale L.A. Scuro n. 10VeronaVRItaly37134
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Cuddy SA, Falk RH. Amyloidosis as a Systemic Disease in Context. Can J Cardiol 2020; 36:396-407. [DOI: 10.1016/j.cjca.2019.12.033] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022] Open
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Mehmood M. Letter by Mehmood Regarding Article, "Three Public Health Interventions Could Save 94 Million Lives in 25 Years: Global Impact Assessment Analysis". Circulation 2020; 141:e3-e4. [PMID: 31928438 DOI: 10.1161/circulationaha.119.043702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Muddassir Mehmood
- Division of Cardiology, Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville
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Conceição I. Novel RNA-targeted therapies for hereditary ATTR amyloidosis and their impact on the autonomic nervous system. Clin Auton Res 2019; 29:11-17. [PMID: 31399774 PMCID: PMC6763402 DOI: 10.1007/s10286-019-00626-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 08/02/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Transthyretin-mediated hereditary amyloidosis (hATTR amyloidosis) is a multisystemic disease with heterogeneous clinical presentation. Hallmarks of the disease are sensory-motor and autonomic neuropathy and cardiomyopathy. Two disease-modifying drugs, inotersen (an antisense oligonucleotide) and patisiran (a small interfering RNA agent), were recently approved for the treatment of hATTR polyneuropathy. We here review the results of the RNA-targeted therapy clinical trials with special emphasis on the endpoints measuring autonomic symptoms and function. METHODS Literature review. We used the terms "autonomic neuropathy", "dysautonomia", "autonomic symptoms", "oligonucleotides", "inotersen" and "patisiran" in patients with hATTR amyloidosis. RESULTS In the NEURO-TTR (inotersen) clinical trial, the modified NIS+7 score (mNIS+7) remained stable in 36% of the patients in the inotersen arm (defined as a change of less than 2 points), and 50% of patients had improved quality of life (Norfolk-QOL-DN score) after 15 months. In the APOLLO patisiran trial, 74% of the patients showed stabilization of the neuropathy, defined as a < 10 points increase on mNIS+7, and 51% of patients showed an improvement of quality of life (Norfolk QOL-DN), favoring patisiran at 18 months. Patients on patisiran had a reduced burden of autonomic dysfunction as measured by the COMPASS-31, and a stabilization of nutritional status, suggesting an effect on gastrointestinal autonomic function. CONCLUSIONS Clinical trials of inotersen and patisiran showed that these agents were able to halt the progression of the disease, with some patients even reducing the burden of polyneuropathy, and improving qualify of life. The information on their impact on autonomic parameters is limited, warranting further dedicated studies.
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Affiliation(s)
- Isabel Conceição
- Department of Neurosciences and Mental Health, CHULN, Hospital de Santa Maria, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal.
- Faculdade de Medicina-IMM, Universidade de Lisboa, Lisboa, Portugal.
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Zhao Y, Xin Y, Song Z, He Z, Hu W. Tafamidis, a Noninvasive Therapy for Delaying Transthyretin Familial Amyloid Polyneuropathy: Systematic Review and Meta-Analysis. J Clin Neurol 2019; 15:108-115. [PMID: 30618225 PMCID: PMC6325356 DOI: 10.3988/jcn.2019.15.1.108] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/23/2018] [Accepted: 09/28/2018] [Indexed: 12/21/2022] Open
Abstract
Background and Purpose Tafamidis functions to delay the loss of function in transthyretin familial amyloid polyneuropathy (TTR-FAP), which is a rare inherited amyloidosis with progressive sensorimotor and autonomic polyneuropathy. This systematic literature review and meta-analysis evaluated the efficacy and safety of tafamidis in TTR-FAP patients, with the aim of improving the evidence-based medical evidence of this treatment option for TTP-FAP. Methods A systematic search of the English-language literature in five databases was performed through to May 31, 2018 by two reviewers who independently extracted data and assessed the risk of bias. We extracted efficacy and safety outcomes and performed a meta-analysis. Statistical tests were performed to check for heterogeneity and publication bias. Results The meta-analysis identified six relevant studies. The tafamidis group showed smaller changes from baseline in the Neuropathy Impairment Score–Lower Limbs [mean difference (MD)=−3.01, 95% confidence interval (CI)=−3.26 to −2.75, p<0.001] and the Norfolk Quality of Life-Diabetic Neuropathy total quality of life score (MD=−6.67, 95% CI=−9.70 to −3.64, p<0.001), and a higher modified body mass index (MD=72.45, 95% CI=69.41 to 75.49, p<0.001), with no significant difference in total adverse events [odds ratio (OR)=0.69, 95% CI=0.35 to 1.35, p=0.27]. The incidence of adverse events did not differ between tafamidis and placebo treatment except for fatigue (OR=0.13, 95% CI=0.02 to 0.72, p=0.02) and hypesthesia (OR=0.16, 95% CI=0.03 to 0.92, p=0.04). Conclusions This systematic review and meta-analysis has demonstrated that tafamidis delays neurologic progression and preserves a better nutritional status and the quality of life. The rates of adverse events did not differ between the patients in the tafamidis and placebo groups. Tafamidis might be a safer noninvasive option for patients with TTR-FAP.
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Affiliation(s)
- Yinan Zhao
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yanguo Xin
- Department of Cardiology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Zhuyin Song
- Department of Neurology, The People's Hospital of Liaoning Province, Shenyang, China
| | - Zhiyi He
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Wenyu Hu
- Department of Cardiology, The First Affiliated Hospital of China Medical University, Shenyang, China.
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Vita GL, Stancanelli C, Gentile L, Barcellona C, Russo M, Di Bella G, Vita G, Mazzeo A. 6MWT performance correlates with peripheral neuropathy but not with cardiac involvement in patients with hereditary transthyretin amyloidosis (hATTR). Neuromuscul Disord 2018; 29:213-220. [PMID: 30718023 DOI: 10.1016/j.nmd.2018.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/20/2018] [Accepted: 11/08/2018] [Indexed: 01/08/2023]
Abstract
Hereditary transthyretin amyloidosis (hATTR) is a life-threatening multisystemic disease with sensory-motor peripheral neuropathy, cardiomyopathy and dysautonomia. Although the six-minute walk test (6MWT) is one of the most popular clinical tests to assess functional exercise capacity in cardiopulmonary and neuromuscular diseases, little is known about 6MWT in evaluating hATTR patients. A prospective single-center pilot study was performed in twenty hATTR patients, comparing 6MWT with widely used outcome measures. After 18 months, fourteen patients were re-evaluated. 6MWT performance was highly related with familial amyloidotic polyneuropathy stage and polyneuropathy disability score, and with CMT examination score, neuropathy impairment score-lower limbs and Kumamoto score. There was no correlation with compound autonomic dysfunction test, modified body mass index and numerous indices of heart dysfunction. After 18 months, familial amyloidotic polyneuropathy stage and polyneuropathy disability score systems were not able to reveal any significant change, whereas all other outcome measures significantly worsened. Among the outcome measures monitoring the neuropathic disturbances, neuropathy impairment score-lower limbs showed the highest responsiveness to change (adjusted effect size: 0.79), followed by CMT examination score (0.67), Kumamoto scale (0.65), 6MWT (0.62). 10MWT showed a very small value (0.21). Compound autonomic dysfunction test had a large value (0.91) whereas modified body mass index a small/moderate value (0.49). 6MWT is a simple and sensitive tool to monitor neuropathic involvement but not cardiac dysfunction in hATTR course.
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Affiliation(s)
- Gian Luca Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina University Hospital, Messina, Italy
| | - Claudia Stancanelli
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina University Hospital, Messina, Italy
| | - Luca Gentile
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Costanza Barcellona
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Massimo Russo
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina University Hospital, Messina, Italy
| | - Gianluca Di Bella
- Unit of Cardiology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina University Hospital, Messina, Italy; Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Anna Mazzeo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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15
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Barroso FA, Judge DP, Ebede B, Li H, Stewart M, Amass L, Sultan MB. Long-term safety and efficacy of tafamidis for the treatment of hereditary transthyretin amyloid polyneuropathy: results up to 6 years. Amyloid 2017; 24:194-204. [PMID: 28758793 DOI: 10.1080/13506129.2017.1357545] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The objective of the present study was to evaluate the long-term safety and efficacy of tafamidis in treating hereditary transthyretin amyloid polyneuropathy. METHODS A prospectively planned interim analysis was conducted on an on-going, phase III, open-label extension study following an 18-month, randomized, controlled study and 12-month, open-label extension study in ATTRV30M patients and a single-arm, open-label study in non-ATTRV30M patients. Thirty-seven ATTRV30M patients received placebo for 18 months, then switched to tafamidis and 38 ATTRV30M patients and 18 non-ATTRV30M patients continuously received tafamidis from day 1, up to 6 years. RESULTS Long-term tafamidis was associated with a favourable safety/tolerability profile, without any unexpected adverse events. Patients initiating tafamidis at the start of the randomized study had less polyneuropathy progression versus those switching to tafamidis following 18 months of placebo and were less likely to progress to the next ambulatory stage after up to 6 years follow-up. In the patients who switched from placebo to tafamidis, polyneuropathy progression and deterioration in quality of life slowed significantly during long-term tafamidis treatment as compared with the previous placebo treatment. In non-ATTRV30M patients, some polyneuropathy progression was observed across all efficacy measures. CONCLUSIONS These data provide evidence for the long-term (up to 6 years) safety and efficacy of tafamidis.ClinicalTrials.gov: NCT00925002.
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Affiliation(s)
- Fabio A Barroso
- a Department of Neurology , Institute for Neurological Research Raúl Carrea, FLENI , Buenos Aires , Argentina
| | - Daniel P Judge
- b Johns Hopkins University Center for Inherited Heart Disease , Baltimore , MD , USA
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Matalonga L, Gort L, Ribes A. Small molecules as therapeutic agents for inborn errors of metabolism. J Inherit Metab Dis 2017; 40:177-193. [PMID: 27966099 DOI: 10.1007/s10545-016-0005-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 11/22/2016] [Accepted: 11/23/2016] [Indexed: 01/03/2023]
Abstract
Most inborn errors of metabolism (IEM) remain without effective treatment mainly due to the incapacity of conventional therapeutic approaches to target the neurological symptomatology and to ameliorate the multisystemic involvement frequently observed in these patients. However, in recent years, the therapeutic use of small molecules has emerged as a promising approach for treating this heterogeneous group of disorders. In this review, we focus on the use of therapeutically active small molecules to treat IEM, including readthrough agents, pharmacological chaperones, proteostasis regulators, substrate inhibitors, and autophagy inducers. The small molecules reviewed herein act at different cellular levels, and this knowledge provides new tools to set up innovative treatment approaches for particular IEM. We review the molecular mechanism underlying therapeutic properties of small molecules, methodologies used to screen for these compounds, and their applicability in preclinical and clinical practice.
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Affiliation(s)
- Leslie Matalonga
- Secció Errors Congènits del Metabolisme-IBC. Servei de Bioquímica i Genètica Molecular, Hospital Clínic, CIBERER-U737; IDIBAPS, C/ Mejía Lequerica s/n, 08028, Barcelona, Spain.
| | - Laura Gort
- Secció Errors Congènits del Metabolisme-IBC. Servei de Bioquímica i Genètica Molecular, Hospital Clínic, CIBERER-U737; IDIBAPS, C/ Mejía Lequerica s/n, 08028, Barcelona, Spain
| | - Antonia Ribes
- Secció Errors Congènits del Metabolisme-IBC. Servei de Bioquímica i Genètica Molecular, Hospital Clínic, CIBERER-U737; IDIBAPS, C/ Mejía Lequerica s/n, 08028, Barcelona, Spain
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Tafamidis in transthyretin amyloidosis: a guide to its use in delaying peripheral neurological impairment in patients with stage 1 polyneuropathy. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-016-0368-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kerschen P, Planté-Bordeneuve V. Current and Future Treatment Approaches in Transthyretin Familial Amyloid Polyneuropathy. Curr Treat Options Neurol 2016; 18:53. [PMID: 27873215 DOI: 10.1007/s11940-016-0436-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OPINION STATEMENT Treatment of transthyretin familial amyloid polyneuropathy (TTR FAP) must be tailored to disease stage. Patients with early stage disease (i.e., without major impairment in walking ability), especially younger patients, should be referred as soon as possible for liver transplantation (LT) in the absence of major comorbid conditions. LT remains the most effective treatment option to date and should be offered to these patients as early as possible. Bridging therapy with an oral TTR stabilizer (tafamidis or diflunisal, according to local access to these treatments) should be started as soon as the diagnosis of TTR FAP is established. Early stage patients who do not wish to or have contraindications to LT should be treated with an oral TTR stabilizer or get access to the newly developed therapeutic options (IONIS TTR-Rx, patisiran, doxycycline/TUDCA). Late stage patients (presenting with significant walking impairment) are usually older and notoriously difficult to treat. They should be offered an oral TTR stabilizer but are not candidates for LT due to a significant rate of perioperative complications and increased risk of progressive neurological and especially cardiac disease despite LT. Access to the different therapies in development should also be considered depending on respective inclusion and exclusion criteria. The abovementioned treatment options were mostly validated in Val30Met mutation patients, but should also be offered to non-Val30Met patients, although mortality rates after LT are higher in these patients. Treatment decisions should be made on an individual basis. Screening for heart, eye, and renal involvement is mandatory for every patient at disease diagnosis and regularly thereafter, even in transplanted patients. Symptomatic treatment should be offered as needed, as well as genetic counseling to at-risk family members. Asymptomatic mutation carriers should benefit from regular screening for early symptoms of disease. Current therapeutic management of TTR FAP will hopefully be changed in the near future with data from the ongoing phase 2/3 studies testing the TTR gene silencing agents. In the longer term, it is likely that combined therapeutic approaches will be necessary to reverse the disease process.
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Affiliation(s)
- Philippe Kerschen
- Service de Neurologie, Centre Hospitalier de Luxembourg, 4 rue Barblé, L-1210, Luxembourg, Luxembourg
| | - Violaine Planté-Bordeneuve
- Service de Neurologie, CHU Henri Mondor, 51 avenue de Lattre de Tassigny, 94000, Créteil, France. .,Groupe de Recherche Clinique Amylose, Université Paris-Est-Créteil, 94000, Créteil, France.
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Waddington Cruz M, Amass L, Keohane D, Schwartz J, Li H, Gundapaneni B. Early intervention with tafamidis provides long-term (5.5-year) delay of neurologic progression in transthyretin hereditary amyloid polyneuropathy. Amyloid 2016; 23:178-183. [PMID: 27494299 PMCID: PMC5359776 DOI: 10.1080/13506129.2016.1207163] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
UNLABELLED Transthyretin hereditary amyloid polyneuropathy, also traditionally known as transthyretin familial amyloid polyneuropathy (ATTR-FAP), is a rare, relentless, fatal hereditary disorder. Tafamidis, an oral, non-NSAID, highly specific transthyretin stabilizer, demonstrated safety and efficacy in slowing neuropathy progression in early-stage ATTRV30M-FAP in a 1.5-year, randomized, double-blind, placebo-controlled trial, and 1-year open-label extension study, with a second long-term open-label extension study ongoing. Subgroup analysis of the effectiveness of tafamidis in the pivotal study and its open-label extensions revealed a relatively cohesive cohort of patients with mild neuropathy (i.e. Neuropathy Impairment Score for Lower Limbs [NIS-LL] ≤ 10) at the start of active treatment. Early treatment with tafamidis for up to 5.5 years (≥1 dose of tafamidis meglumine 20 mg once daily during the original trial or after switching from placebo in its extension) resulted in sustained delay in neurologic progression and long-term preservation of nutritional status in this cohort. Mean (95% CI) changes from baseline in NIS-LL and mBMI were 5.3 (1.6, 9.1) points and -7.8 (-44.3, 28.8) kg/m2 × g/L at 5.5 years, respectively. No new safety issues or side effects were identified. These data represent the longest prospective evaluation of tafamidis to date, confirm a favorable safety profile, and underscore the long-term benefits of early intervention with tafamidis. TRIAL REGISTRATION ClincalTrials.gov Identifier: NCT00409175, NCT00791492, and NCT00925002.
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Affiliation(s)
- Márcia Waddington Cruz
- a Hospital Universitário Clementino Fraga Filho (HUCFF), Universidade Federal do Rio de Janeiro (UFRJ) , Rio de Janeiro , Brazil
| | | | | | | | - Huihua Li
- b Pfizer , New York , NY , USA , and
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20
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Coelho T, Merlini G, Bulawa CE, Fleming JA, Judge DP, Kelly JW, Maurer MS, Planté-Bordeneuve V, Labaudinière R, Mundayat R, Riley S, Lombardo I, Huertas P. Mechanism of Action and Clinical Application of Tafamidis in Hereditary Transthyretin Amyloidosis. Neurol Ther 2016; 5:1-25. [PMID: 26894299 PMCID: PMC4919130 DOI: 10.1007/s40120-016-0040-x] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Indexed: 11/24/2022] Open
Abstract
Transthyretin (TTR) transports the retinol-binding protein-vitamin A complex and is a minor transporter of thyroxine in blood. Its tetrameric structure undergoes rate-limiting dissociation and monomer misfolding, enabling TTR to aggregate or to become amyloidogenic. Mutations in the TTR gene generally destabilize the tetramer and/or accelerate tetramer dissociation, promoting amyloidogenesis. TTR-related amyloidoses are rare, fatal, protein-misfolding disorders, characterized by formation of soluble aggregates of variable structure and tissue deposition of amyloid. The TTR amyloidoses present with a spectrum of manifestations, encompassing progressive neuropathy and/or cardiomyopathy. Until recently, the only accepted treatment to halt progression of hereditary TTR amyloidosis was liver transplantation, which replaces the hepatic source of mutant TTR with the less amyloidogenic wild-type TTR. Tafamidis meglumine is a rationally designed, non-NSAID benzoxazole derivative that binds with high affinity and selectivity to TTR and kinetically stabilizes the tetramer, slowing monomer formation, misfolding, and amyloidogenesis. Tafamidis is the first pharmacotherapy approved to slow the progression of peripheral neurologic impairment in TTR familial amyloid polyneuropathy. Here we describe the mechanism of action of tafamidis and review the clinical data, demonstrating that tafamidis treatment slows neurologic deterioration and preserves nutritional status, as well as quality of life in patients with early-stage Val30Met amyloidosis.
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Affiliation(s)
- Teresa Coelho
- Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.
| | - Giampaolo Merlini
- Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | | | | | - Daniel P Judge
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Mathew S Maurer
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | | | | | | | | | - Pedro Huertas
- Massachusetts General and McLean Hospitals, Harvard Medical School, Boston, MA, USA
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Parenteral nutrition improves nutritional status, autonomic symptoms and quality of life in transthyretin amyloid polyneuropathy. Neuromuscul Disord 2016; 26:374-7. [PMID: 27132122 DOI: 10.1016/j.nmd.2016.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 03/24/2016] [Accepted: 03/28/2016] [Indexed: 11/24/2022]
Abstract
Transthyretin familial amyloid polyneuropathy (TTR-FAP) is an inherited amyloidosis, leading to death in about ten years in most cases due to cardiac failure or wasting syndrome. Previous studies showed that modified body mass index was related to time before death, duration of gastrointestinal disturbances, malabsorption and functional capacity. We report two patients in whom nutritional status worsened despite diet modification, hypercaloric supplement and two relevant therapeutic approaches such as liver transplant and tafamidis meglumine, respectively. The first patient, a 52-year-old lady carrying Thr49Ala mutation, had a disease duration of twelve years and had lost weight up to 35 kg because of daily diarrhea. The second patient, a 63-year-old man with Glu89Gln mutation and a disease duration of fifteen years, was in the New York Heart Association (NYHA) Functional Classification class III and his weight was 39 kg. In both cases, a peripherally inserted central catheter was placed for parenteral nutrition. It allowed to improve their nutritional status and clinical conditions, with body weight gains of 11 and 8 kg in a one year follow-up, respectively. Moreover, reduction of autonomic symptoms including postural hypotension, nausea and diarrhoea was recorded with ameliorated quality of life. Our experience suggests that parenteral nutrition may be useful in reducing complications and disabilities in TTR-FAP patients, even when all dietary adjustments have been ineffective. Reasonably, the improvement in nutritional status may prolong survival in TTR-FAP patients.
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Monitoring effectiveness and safety of Tafamidis in transthyretin amyloidosis in Italy: a longitudinal multicenter study in a non-endemic area. J Neurol 2016; 263:916-924. [DOI: 10.1007/s00415-016-8064-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 10/22/2022]
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Waddington Cruz M, Benson MD. A Review of Tafamidis for the Treatment of Transthyretin-Related Amyloidosis. Neurol Ther 2015; 4:61-79. [PMID: 26662359 PMCID: PMC4685869 DOI: 10.1007/s40120-015-0031-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Indexed: 12/24/2022] Open
Abstract
Transthyretin (TTR)-related amyloidosis (ATTR) is a devastating disease which affects a combination of organs including the heart and the peripheral nerves, and which has a fatal outcome if not treated within a average of 10 years. Tafamidis, or 2-(3,5-dichloro-phenyl)-benzoxazole-6-carboxylic acid, selectively binds to TTR with negative cooperativity and kinetically stabilizes wild-type native TTR and mutant TTR; tafamidis therefore has the potential to halt the amyloidogenic cascade initiated by TTR tetramer dissociation, monomer misfolding, and aggregation. The first tafamidis trial, Fx-005, evaluated the effect of 18 months of tafamidis treatment (20 mg once daily) on disease progression, as well as assessing its safety in TTR-FAP Val30Met patients. The secondary objective of this trial was to study the pharmacodynamic stabilization of mutated TTR. Tafamidis proved effective in reducing the progress of neuropathy, and in maintaining the nutritional status and quality of life of stage 1 (able to walk without support) Val3OMet TTR-FAP patients. Furthermore, TTR stabilization was achieved in more than 90% of patients. An extension study, Fx-006, was conducted to determine the long-term safety and tolerability of tafamidis and to assess the efficacy of the drug on slowing disease progression. No significant safety or tolerability issues were noticed. Taken together, the results from both trials indicated that the beneficial effects of tafamidis were sustained over a 30-month period and that starting treatment early is desirable. Results are expected from an extended open-label study but data that have already been presented show that long-term use of tafamidis in Val30Met patients is associated with reduced progression in polyneuropathy. Tafamidis was initially approved for commercial use in Europe in 2011 and has since been approved for use in Japan, Mexico, and Argentina where it is used as a first-line treatment option for patients with early-stage TTR-FAP. Patients should be carefully followed at referral centers to ascertain the individual response to treatment. In cases of discontinuation, liver transplantation and enrollment in clinical trials of novel drugs aimed mostly toward suppression of TTR production are options.
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Affiliation(s)
- Márcia Waddington Cruz
- Amyloidosis Research and Treatment Center (CEPARM), University Hospital (HUCFF), Federal University of Rio de Janeiro, Rio De Janeiro, Brazil.
| | - Merril D Benson
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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